Report and photos compiled by Rithy Chau, Telemedicine Physician Assistant at SHCH On Tuesday, October 21, 2003, Rattanakiri Provincial Hospital (RPH) staff with their Telemedicine(TM) Partners from Sihanouk Hospital Center of HOPE (SHCH) in Phnom Penh, Cambodia, began the seventh TM clinic. The patients were examined by clinicians from RPH and SHCH and their data were transcribed along with digital pictures of the patients, then transmitted and received replies from their TM partners in Boston and Phnom Penh. SHCH staff (Rithy Chau, PA-C and Somontha Koy, RN) were present during the clinic hours to assist in recording and translating H&P (from French/Khmer into English) and to monitor and facilitate the data transmission and communication. There were six doctors and a medical assistant (or PA) of RPH participating in this month TM clinic along with Pharmacist Ly Channarith, who took digital photos and helped to direct the clinic. There were seven new cases and one follow up patient from the May/September 03 clinic. All their data and photos were transmitted. One case was seen and presented by Koy Somontha, RN, with supervision of PA Rithy Chau. Another special (follow-up) case (SS#00027) was added in this month clinic and was seen by Dr. Peng Lin and Dr. Kok San. The data for this patient was transmitted on Tuesday, October 28, and will be included in this month clinic website publishing with replies from both SHCH in Phnom Penh and Partners in Boston. [Please note that some of the patients’ data collected, transcribed, and communicated were done by the RPH staff and were left in its crude form so as for viewers to understand the challenge of medicine practiced in remote, rural setting of Cambodia. The CamShin satellite was operating somewhat smoothly with minor interruptions during this month TM clinic.] The following day, Wednesday, October 22, 2003, the TM clinic opened again to send the rest of the cases and receive the same patients for further evaluations, treatments and management. Clinicians from SHCH discussed briefly case by case with the local (RPH) telemedicine staff concerning each patient’s treatment and management using information/replies received from the TM partners that morning. In the late afternoon, the local medical staff would then followed up with the agreed plan of treatment and management with each patient seen. Finally, the data of the follow-up for patient treatment and management would then be transcribed and transmitted to the PA Rithy Chau at SHCH who compiled and sent for website publishing. The followings detail e-mails and replies to the medical inquiries communicated between TM clinic at RPH and their TM partners in Phnom Penh and Boston :
-----Original Message----- Dear All, Please be informed that the next TM clinic at the Rattanakiri Provincial Hospital will be held On Tuesday, October 21 at 8:00 AM local time for one full day. The data of the patients are expected to entered and transmitted to those of you in SHCH and partner (Boston) that evening. Please try to make your replies by noontime the following day, Wednesday 22 October. The patients will be asked to return that afternoon on Wednesday to receive treatments and plan of follow-up or refer. Thank you for your cooperation and service. Best regards, Channarith Ly
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Tuesday, October 21, 2003
-----Original Message----- Dear All, This is the first case of this month patient PT#00036.There will be one more photo to be sent for this patient. Best regards, Channarith/Rithy Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: PT#00036 , 47F, Village III
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-----Original Message----- I don't see evidence for cardiac ischemia: young middle aged woman, not angina pain pattern, not hypertensive, normal heart size, normal ekg. She may have gastritis or GERD associated with irritable bowel symptoms. Less likely peptic ulcer disease without clear exacerbation of pain. Palpitations seem more likely anxiety or stress related give multiple other somatic symptoms like blurred vision, tinnitus and shortness of breath.. I would check serology for H. pyloria. UGI series or endoscopy to confirm GERD or gastritis would be ideal. In the meantime, cimetidine would be fine--30 days would be preferable if this was an ulcer. I would avoid aspirin since this could aggravate gastritis or ulcer. Atenolol seems unnecessary. Perhaps more psychosocial history and counseling would be more effective. Heng Soon Tan, M.D.
-----Original Message----- Dear Channarith/Rithy, Hx and PE sounds like GERD. Since she has taken some antacid or ?H2-blocker already, we would try omeprazol 20 mg a day, metoclopramide 5 mg to 10 mg one hour before each meal and before bed time. Avoid not to have dinner within 3 hours before bed and put something underneath the head of the bed to make it elevated to prevent nighttime reflux. Avoid frequent bending, avoid large meals, or take a rest right after meal, no smoke, no alcohol, no chocolate. Obesis needs to reduce weight. The treatment would be 2 to 3 months. Palpitation with heart rate 75/min. So we would screen for other causes of palpitation like anemia, hyperthyroidism, drugs and anxiety. Just HX and PE is enough, any pallor, heat intolerance, weight loss, tremor,... We cannot find signs of cardiac ischemia on ECG. We would suggest not to prescribe atenolol and ASA. Best regards, Jennifer/Bunse
-----Original Message----- Dear All, This is the patient MV#00037.There will be more photos to be sent for this patient. Best regards, Channarith/Rithy Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: MV#00037, 2M, Chey Udom Village
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-----Original Message----- What a cute child! It sounds like this child has a large VSD and should be transported to the Cardiac Hospital. Hhope this helps. Mike de Moor Pediatric Cardiology.
-----Original Message----- Dear Channarith/Rithy, A lovely boy. We would love to bring him to Phnom Penh Heart Center near Calmette hopsital. We wish him good luck. Regards, Jennifer/Bunse
-----Original Message----- Dear All, This is the patient CS#00038. There will be some more photos to be sent. Best regards, Channarith/Rithy Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: CS#OOO38 , 56 F, VILLAGE III
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-----Original Message----- Hello, Warmest greetings from Boston. She seems to have 4 problems. First, for the abdominal pain. If she does not have black or bloody stool then an ulcer is unlikely. She may have gastritis. A trial of Omeprazole would be okay. If this works but the symptoms come back, consider empiric treatment for Helicobacter pylori infection of the stomach. Also, if Omeprazole is too expensive, cimetidine or famotidine should be fine. Second, for the lower abdominal pain. This may be due to mild intestinal upset, or perhaps parasites. If possible, do a stool examination for ova & parasites. Otherwise just wait and see if she gets better. If she does not get better, then a trial of Tinidazole or Albendazole would be reasonable. Third, she had high blood pressure on one measurement. This should be checked a few more times before we can be sure she really has chronic hypertension. Today her pressure is normal, so she probably does not really have hypertension. If the diagnosis is confirmed, modify her diet to avoid salt, and give Hydrochlorthiazide 25 mg once daily (for the rest of her life) and reassess the blood pressure to see if this is enough. Finally, she has a headache and some neck stiffness. This is most likely due to stress. Speak to her about stress in her life and be sure she does some kind of recreational activity once in a while. Also, if she does not have any physical activity in her normal life, she should be encouraged to get some exercise. With best wishes, Danny ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Danny Pallin, MD, MPH Department of Emergency Medicine Brigham and Women’s Hospital NH-122H Harvard Medical School 75 Francis St., Boston MA 02115 tel: 617-525-6614 fax: 617-264-6848
-----Original Message----- Dear Channarith/Rithy, 1 year on and off headache, neck tension, blurred vision and one report of high SBP 180 mmHg, and on clonidine 4 days ago. Now BP is normal and no clonidine. Clonidine can cause rebound HTN, so we would like to observe her closely for a few days. Clonidine low dose may help tension headache/migraine, but we preferred propranolol + amitriptyline. Visual problem can cause headache also, so we suggest to have her eyes check by opthalmologist and optician whether she nedds glasses or not. A cervical X-ray just to rule out Pott's (we have seen several) and we would suggest Paracetamol 500 mg QID PRN pain. 5 days of epigastric pain and tender. We suggest only omeprazol 20 mg a days for 2 months for the moment. Best regards, Bunse
-----Original Message----- Dear All, This is the patient TP#00039 and the rest of photos will be sent next. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic Patient: TP#00039, 35y.o,female, Borkeo
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-----Original Message----- Agree with right sided lung abscess. I assume her dentition is poor. Three AFB negative. Can you do sputum cultures (to assess for klebsiella, etc). Would add clindamycin. Assuming not tuberculosis, recommend 4-6 weeks po clindamycin. Edward T. Ryan,
M.D., DTM&H Administrative
Office Tel: 617 726 6175
-----Original Message----- Dear Chhannarith/Rithy, Signs and symptoms are more point to respiratory problem. We are not clear to when the 2 CXR were taken, and it is not clear to us to are there any dilated bile ducts. But the fever and high WBC with high PMN would suggest infection. According to the data given, we thing of lung abscess or biliary infection. The patient needs to hospitalized. To be safe we would recommend to use ceftriaxone 2 g IV a day and metronidazole 500 mg IV TID for 10 days. A sputum Gram stain should be done or should be promoted. Jennifer/Bunse
-----Original Message----- Dear All, This is patient CS#00040 and the rest of photos will be send later. Best regards, Channarith/Rithy Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners
Patient: CS # 00040 ,22Y F ,Village I
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-----Original Message----- From: List, James Frank,M.D.,Ph.D. [mailto:JLIST@PARTNERS.ORG] Sent: Wednesday, October 22, 2003 3:11 AM To: 'kirihospital@yahoo.com ' Cc: 'tmed_rithy@online.com.kh '; Kelleher-Fiamma, Kathleen M., Telemedicine Subject:
Patient CS#00040, 22 Y F, village i
In summary, the patient is a 22 y/o female with a history of post-partum heart disease of unclear type or etiology who now presents with cough, hemoptysis, dyspnea, fever, and chest pain. EKG shows evidence right ventricular hypertrophy, and CXR shows right atrial enlargement (the x-ray does not come through clearly enough to see if there are granulomata or infiltrates). Putting this together, the likely diagnoses are infection (bronchitis, pneumonia, or TB) or recurrent pulmonary emboli. The latter makes sense as a cause of post-partum right heart failure and subsequent right ventricular hypertrophy with right atrial enlargement. I would not give Lasix, as the patient has evidence of cor pulmonale and is likely to be preload dependent. I would not give digoxin, as this improves symptoms of left heart failure but has little role in cor pulmonale and an unacceptable risk profile. Empiric antibiotic therapy for pneumonia and bronchitis could be undertaken while a PPD is placed and sputum is examined for and cultured for acid-fast bacteria. If these are positive, the treatment should be switched to appropriate anti-tuberculosis medications. If the X-ray looks suspicious for TB, or if there is a high clinical suspicion, treatment can be empirically started while waiting for the results of the above tests. However, the best unifying diagnosis for the patient's past and current medical history is recurrent pulmonary emboli. This would require a diagnostic workup which should be performed right away if possible. In the U.S., the modalities to investigate include ventilation:perfusion scanning, spiral CT angiography, and pulmonary angiography to image the pulmonary vasculature. Ultrasound, venography, and even sometimes MRI is used to look for evidence of a source clot - usually in the lower extremities (of course, a physical examination looking for signs of deep venous thrombosis is the place to start - looking for signs such as calf swelling and tenderness and a palpable cord). Finally, a d-dimer test is highly sensitive for pulmonary embolism, such that if it is not elevated, there is a low chance that this is a pulmonary embolism. The workup locally, of course, must conform to the available technology. James F. List, M.D., Ph.D. Endocrinology, Massachusetts General Hospital
-----Original Message----- Dear Channarith/Rithy, There is cardiomegaly, artial enlargement, pulmonary artery enlargement and no infiltrate on CXR. RVH with strain pattern on ECG. No LVH or AFib on ECG. No lung crakles, no edema. She has fever of 38 degree, SOB, cough and hemoptysis. WBC is normal. We think she may has MS or pulmonary HTN causing her hemoptysis, and abnormal CXR/ECG. We would love to request echocardiogram and decide later whether she should continue her digoxin or not. Her furosemide may be a lot. Could you try just 20 mg BID and see what happen. You may add ASA low dose. If you worry about bronchitis or pneumonia because of fever, it is OK to use Amoxicillin 500 mg TID for 7 days. OK with sputum exam. Have a nice day, Jennifer/Bunse
-----Original Message----- Dear All, This is the patient IP#00041 and the rest of photos will be sent later. Best regards, Channarith/Rithy Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: IP#00041, 58 y.o, M, village I
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-----Original Message----- Comments of phyiscal exam: Is 5cm the total liver span or is that the measurement below the costal margin? How is it in the gallbladder ultrasound that makes you conclude that he has cholecystitis? Does he have gallstones? Is the WBC at the time of diagnosis or after 10 days of treatment?
Comments on diagnosis: The chest infiltrates at the apex of the left lower lobe do raise the possibility of tuberculosis. If indeed cavities are present, that would support the diagnosis. However, the AFB smears were negative 3 times. Differential diagnoses: chronic bronchiectasis with pneumonia or flare of bronchitis. One sided infiltrate is against diagnosis of heart failure. What is more impressive is the cardiomegaly. The history of epigastric pain, hepatomegaly, shortness of breath makes me worry about pericardial tamponade from pericarditis. If he has tuberculosis, I would worry about chronic pericarditis from tuberculosis.Does he have paradoxical pulse or paradoxical rise in neck veins when he takes a deep breath? Low voltage and ST elevation changes on EKG could help in diagnois of pericariditis and tamponade. Echocardiogram would make definitive diagnosis. Looks like he has chronic falciparum malaria that was treated as well. There is no evidence to conclude he has malignant gastric ulcer or peptic ulcer disease. I'm not sure there is basis to conclude he has cholecystitis either. Comments on management: For chest infiltrate: I would check a few more sputum for AFB smear and culture. Could you bronchoscope him if necessary? For cardiomegaly: I would arrange echocardiogram. He may need pericardiocentesis to confirm diagnosis [AFB smear and culture] and manage pericaridal tamponade [drain]. Only if TB is confirmed, I would treat him for TB. In the meantime, he seems to have received adequate treatment for bronchitis/bronchiectasis/pneumonia. If falciparum persists, he may need supplementary treatment with mefloquine or doxycycline. Heng Soon Tan, M.D.
-----Original Message----- Dear Channarith/Rithy, The patient came with severe epigastric pain, black stool, CXR has alveolar infiltrate on the left part of the lung with high WBC, Pf +1, drinking and smoking history. On ceftriaxone 2g for 9 days, artemether. We think of PUD and pneumonia. Since he is a drinker, did he aspirate when he come in? But aspiration pneumonia should often be on the right lower lobe. When was the CXR done? Anyway, we would like to give him Omeprazol 20 mg BID, Amoxicilline 500 mg TID and Metronidazole 500 mg TID for 14 days, then omeprazole 20 mg 2 months more. This is to treat his severe dyspepsia with black stool (eradicate H. pylori) and to cover his lung. It is OK to continue his TB, you follow national TB protocol for smear negative PTB, we think. Again sputum Gram stain should be promoted. Jennifer/Bunse
-----Original Message----- Dear Sothero, This is a report of a patient who living in this village. Her name's Pann Chan Tour, she's fifty years old. She has four sons and three daughters. She is a farmer. On Monday, September 08th, 2003 she met me to talk about her problem. She got numb disease since the Pol Pot regime. Nowadays her right palm of the hand has withered. She couldn't close her hand and couldn't do anything, her body was numb also. She said that she sold her cows for buying the medicines but she still got this disease. She needs our organization to send her to the hospital. Finally she said that she have a lot of children. They need her feeding. Best regards, Boreirath
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-----Original Message----- Dear Boreirath, Thank you for your report about the patient. I think the first step is for her to come to the telemedicine program at the hospital in Banlung. When she comes, we will be admitted to the program and she will receive the further advices from the specialized doctor. Best regards, Thero
-----Original Message----- Dear bernie, We would like to get the patient from village ,if the motorman can take her from village to hopital for TM clinic on next trip . The telemedicine clinic will be held on21,22 October and the patient can come on 20 ,October.Through the TM clinic ,we can receive the recoment from SHCH or Boston to refer this patient or not ? Best regards, Channarith Ly
Dear Thero,
----- Original Message -----
Dear Bernie, Note: forwarded message attached. Do you Yahoo!? The New Yahoo! Shopping - with improved product search > ATTACHMENT part 2 message/rfc822 From: "Postman - School 68" To: Subject: Patient Date: Fri, 10 Oct 2003 08:07:55 +0700 Dear Mr. Bunthan,
I would like to inform you in the attachment. Please take a look.
Best regards,
Boreirath > ATTACHMENT part 2.2 application/msword name=Reference disease.doc
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From: "Sing Seda" <seda@bizdaily.forum.org.kh>
-----Original Message----- Dear Boreirath I received you message with attach file.In this case you should refer her to hospital for evaluation.Could you send her with the motorman?.Anyway, we have a TM clinic next week on 21 October. Best regards,
Channarith
Ly Dear Kirihospital, I would like to inform you about the patient. Please take a look in attachment file. Best regards, Boreirath
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-----Original Message----- Dear All, This is the patient ST#00042 and the rest of photos will be sent later. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with Patient: ST#00042, 53F, Sre Ankrung Village
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer. Do you
Yahoo!? -----Original Message----- From: Cusick, Paul S.,M.D. [mailto:PCUSICK@PARTNERS.ORG] Sent: Tuesday, October 21, 2003 10:55 PM To: 'kirihospital@yahoo.com' Cc: 'tmed_rithy@online.com.kh'; Kelleher-Fiamma, Kathleen M., Telemedicine Subject: case reply This woman likely has metastic breast cancer given the interval growth in the mass and the spread to the axillary lymph nodes. tissue diagnosis will confirm diagnosis and stage of breast cancer. it is difficult to predict she would be a candidate for XRT until tumor confirmed and tissue type determined. consultation with an oncologist would be beneficial. She may need palliative surgical excision of left axillary lymph node to relieve pain in left arm. Analgesics would be the treatment of choice until she can see oncologist. Paul Cusick
-----Original Message----- Dear Rithy, two questions: 1. Are there supraclavicular lymph node metastasis? One picture looks like showing a swelling in this area. And is the axillary lymph node mobile? 2. What about the liver? Are there nodular infiltrates? If there are supraclavicular lymph node metastasis or liver metastasis, the best would be to give adequate pain medication and keep the patient at home. If both questions can be answered with no, then ask the surgeon in Ratanakiri if he can do a mastectomy and axillary clearance, if not might have to consider to bring her to Phnom Penh. Norodom Sihanouk might charge her for the operation around 125 USD, around 20 USD extra for a histology. You might have to consider to bring her to SHCH instead, although our capacity right now is very limited. She might need to stay in town for 3-4 weeks and may be gets surgery done in two weeks earliest. Kind regards Cornelia Haener
-----Original Message----- Dear Dr. Cornelia and all, Thank you for your prompt response to our case patient ST#00042. To your two questions posed to us, the answers to these are: no to both (ie. no supraclavicular LN, no nodular infiltrate of the live according to the DR. who did the US). The surgeons here can do an operation with the consent of the patient, but they want to know whether they should do a simple mastectomy with axillary LN clearance or should they do a total mastectomy (including removing of the left pectoris?) with the LN clearance. What is your recommendation on this? RSVP today if possible. Again thank you for participating in patient care for the TM clinic Oct 03. Best regards, Dr. Bunthak/Rithy
-----Original Message----- From: hopestaff@online.com.kh [mailto:hopestaff@online.com.kh] Sent: Thursday, October 23, 2003 9:26 AM To: Kiri Hospital Subject: Re: Rattanakiri Provincial hospital TM clinic patient ST#00042 Dear Channarith/Rithy, the surgeon should do a modified radical mastectomy including pectoralis fascia and axillary clearance. If the pectoralis fascia is invaded, then a radical mastectomy with removal of pectoralis muscles would be appropriate. Kind regards Cornelia
-----Original Message----- Dear All, This is a follow up patient PN#0005 and one photo. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with Patient: PN#0005, 37yo, F, village I
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-----Original Message----- From: Paul Heinzelmann, MD [mailto:pheinzelmann@partners.org] Sent: Wednesday, October 22, 2003 7:09 AM To: kirihospital@yahoo.com Cc: tmed_rithy@online.com.kh; tmed1shch@online.com.kh; jvedar@partners.org; ph2065@yahoo.com Subject: PN#0005, 37 yo female Montha, Thank you for this interesting patient. Summary: 37 yo female with continued cough, SOB, weakness. She also suffers from headache, sneezing, dizziness. EKG: inverted T waves in V1, V2, flat in III History: Why was she on atenolol/ Why is she on amitriptyline? Physical Exam: I assume no pedal edema, which if present might make us consider heart failure as a cause of cough in a patient without fever. Recommendations for Assessment & Plan: 1. EKG: inverted T waves in V1, V2, flat in III _ this can simply be a normal variant. Repeat if symptoms persist and look for changes. 2. SOB/cough: lack of fever suggests but doesn_t exclude infectious causes a. Consider upper respiratory infection, allergic post nasal drip, GERD not controlled adequately. (Early ascaris infection can cause SOB, cough with allergic-type symptoms too.) X-ray would be helpful if symptoms persist _especially if fever or chills Cetirizine seems appropriate for now 3. Limb numbness: more common causes _ hypothyroidism, B12/folate deficiency. 4. Finally consider medication causes of symptoms: Atenolol may cause dizziness or drowsiness and should not be stopped abruptly. Cetirizine may cause dizziness or drowsiness. Amitriptyline
Omeprazole 7 Can also cause drowsiness, dizziness, or headache I hope this is helpful. Thanks again for this interesting case. Sincerely, Paul Heinzelmann, MD
-----Original Message----- Dear Channarith/Rithy and Montha, This is a woman with allergic rhinitis with post-nasl drip and possible asthma induced by the allergic rhinitis. Would it be possible to get steroid nasal spray for her allergic rhinitis? I think she can try to buy it locally, or at least in Phnom Penh. She came in with cough, SOB, no wheeze and no rales on PE. Because her WBC is high, we wonder if there is an infection going on. We would like a CXR to rule out pneumonia. Does she has dysuria? Does she has sinuses tender? A flipped T in V1 to V2 may be normal, and may not be ischemic especially in women not menopause. SOB seems to be intermittent, are there any wheeze at that time or does she has wheeze or chest tightness or SOB at night or early morning. If yes, we would try salbutamol inhaler PRN with steroid inhaler such as beclomethasone 250 microgram BID. She seems do not have complaints on abdomen. We would suggest not to use omeprazol. Cough and hypersalivation could also be from Loiffer syndrome (parasite passage to the lung and throat). We would suggest albendazole 400 mg BID for 5 days. Is it amitriptylline for anxiety/depression disorder? If there were enough evidence, we would suggest low dose first. Start 1/4 of 25 mg tab. at nigth increase to 1/2 in 1 week and stay on this dose until next month. Infrom the patient of dry mouth and sleepy. Regards, Jennifer/Bunse
-----Original Message----- Dear All, This is a special case,SS#00027 and the rest of photo will sent later. Best regards Channarith/Kok San Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: SS#00027, 67 M , Village I .
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer Do you Yahoo!?
-----Original Message----- Dear All, This is a patient seen earlier in the TM clinic with cardiac problem and was referred to Calmette for 2D echo (don't know his result). He was dx at the TM clinic with RBBB (on EKG) and dyspepsia (GERD?). He has a previous hernia operation on his L inguinal area in May03 and apparently now, the hernia is really bothering him. I was not sure whether the H&P sent now presented with strangulation problem or not. No list of medications was given, but they just ask if this patient can be referred to SHCH for further evaluation. Can Ruth or Cornelia respond to this case since it may be a possible surgical case? It looks like he is febrile also, should they put him on an antibiotic--maybe ceftriaxone or oflox IV (if they have the latter) and some pain medication? From the picture I see that they are trying to reduce it already. In the meanwhile, I'll communicate to them to inquire more on the H&P of this patient with whatever tx given already. Thanks for your help. Regards, Rithy
-----Original Message----- Dear Channarith and Dr. San, I received this late in the day already. I'll will communicate to you tomorrow. I ahve written a note to all the TM team at SHCH to ask for recommendation already. Once I hear from them, I'll reply to you. Remember, TM is not for an emergency case. If this is an emergency case, please respond with your best decision or management of this patient immediately and do not wait for our reply nor one from Boston. If he is not an urgent case, can you provide us with more info on the treatment he has received from the Drs. at RPH. Is it a direct or indirect hernia? Were you able to reduce it at all? Why could he not go back to the Dr. who did the operation in the past for treatment? How long has he been hospitalized at RPH? If he is febrile (38C) from your exam, do you know from which source that may cause this fever? Is it from his urinary cath? Finally, make sure you treat his chest pain, if it is cardiac in nature--what heart medications is he on? Regards, Rithy
-----Original Message----- Dear Rithy, it sounds as if this patient has a strangulated recurrent inguinal hernia, may be already with beginning migration of bacteria and beginning peritonitis. DDx Colon ileus due to colorectal cancer, responsible for hernia initially and recurrence ( so called secondary hernia due to high intraabdominal pressure ). In both cases the patient needs an emergency operation. If this is not possible in Ratanakiri and no hospital with adequate facility closer by, the best is to send him to Phnom Penh immediately, as fast as possible. Suggested treatment for now: Stop any attempt of reduction!!!!! Foley catheter, NG tube Ceftriaxone 2 gr IV qD, Metronidazole 500 mg IV q8, cimetidine 200 mg IV q6, enough pain medication, best is morphine IV, also gives some cardiac protection through reduction of preload. IV fluids LR 3 l/24 hours, increase if urine output < 30 cc/hour till urine output is >=30 cc/hour. Try to send some strong donors with him(at least 1 unit) or if he goes by plane send them by car immediately so that we can send them later to refill the pool, if we need to get pool blood. They should do malaria smears in the donors and only send malaria negative donors, strong, not anemic, best males, at least two persons. Please let them know that they should inform the patient that he might be very sick and carries a high risk of morbidity and mortality, but most likely would not survive without procedure. Thanks Cornelia
-----Original Message----- Dear Dr. Bunthak and Channarith, This is the response Dr. Cornelia was instructing me last night. I have spoken to and agreed with Dr. San last night about these steps which needed to be done before the patient arrive at SHCH. Please read them again and make sure that each of the step was being followed to help the patient with his condition. Make sure the relative who comes with him on the plane knows his history in order to help the evaluation at SHCH since he is "dumb" (unable to speak for himself). and that this relative is close to him (e.g. his wife, child or close relative) to help him out during his stay at SHCH and post surgical care. Remember to inform your patient and those who come with him that SHCH is not responsible for their travel, accomodation, food, extra medicine (not available here), etc. They need to arrange all these on their own. Also, inform them that in traveling, it may worsen his condition and possible risk for mortality (death), but as soon as they arrive in PP, they can come directly to SHCH without delay. Once arrived at SHCH, they can contact me by phone 011623805 or just tell the security up front that they come from Rattanakiri through TM project and is expecting to meet with Rithy Chau. I'll inform the security about this case ahead of time. Regards, Rithy
-----Original Message----- Dear Rithy, The patient SS#00027 left from Rattanakiri about 1o'clock at this afternoon with his daughter by plane.They have enough money for travelling and have their relative in Phnom Penh.Please let me know when they arrived at SHCH. Thank you for your coorperation. Best regards, Channarith
-----Original Message----- Dear Channarith/ Dr. San, Thank you for the note. The patient arrived yesterday afternoon after 2PM and was seen by SHCH surgeon Dr. Cornelia and her colleague and evaluated the patient with a reducible left inguinal hernia which is not an urgent surgical case. He was referred back to me in the medical department and I evaluated him this morning repeating some of the tests and was found to have normal CXR, his lab results (CBC, Chem, BUN, Creat, Gluc) were all within normal limit. His physical exam was repeated this AM and found positive for slight tremor, but normal neuro exam except he was mildly hyperreflexic. He was dx with L. inguinal hernia (reducible), GERD, constipation, possible ischemic heart dz (from his previous 2D cardiac echo), and possible vit B deficiency (2nd to EtOH abuse?). We are treating him with B-complex 100cc IV qd x 3d (done in SHCH ED), propranolol 40mg 1/4 tab po bid, omeprazole 20mg 1 po qd, docusate gel 100mg 1 po qhs prn constipation, MTV 1 po qd, and Paracetamol 500mg 2 po tid prn pain. After he finishes receiving the 3 doses of B-complex, he'll be referred back to surgical department for schedule of elective surgery of his hernia repair. This was a challenging case since he could not speak and history was based on the past documents and your H&P presentation. The only family member accompaning him was his niece who hardly knew anything about him since she lived in Phnom Penh. I'll inform you of other news about him in the future. Reagrds, Rithy
Wednesday, October 22, 2003 Follow-up Report for Rattanakiri TM ClinicOne follow up patient from May/September clinic returned for this month TM. The other 7 patients seen were new to the TM clinic at Rattanakiri Provincial Hospital (RPH). One special (follow up) case, SS#00027, was seen about one week after this month clinic. Their data were transmitted and received replies from both Phnom Penh and Boston. Per advice sent by Partners in Boston and Phnom Penh Sihanouk Hospital Center of HOPE, the following patients were managed and treated per local and SHCH medical staff: [Please note that in general the practice of dispensing medications at RPH for all patients is limited to a maximum of 7 days treatment with expectation of patients to return for another week of supplies if needed be. This practice allows clinicians to monitor patient compliance to taking medications and to follow up on drug side effects, changing of medications, new arising symptoms especially in patients who live away from the town of Banlung and/or illiterate.] Patient PN#0005, 37F, Village IFinal assessment: 1) Allergic Rhinitis 2) Helminthic Infection? 3) Anxiety 4) Chronic Bronchitis vs. Asthma?? This patient was prescribed with medications (to be bought at the market) as follows:
Patient’s chest x-ray was done and showed normal structures on 11/4/03. Patient SS#00027, 68M, Village IFinal assessment: 1) Left inguinal hernia 2) GERD 3) Constipation 4) IHD?? 5) Vit Deficiency This patient was prescribed with medications from SHCH pharmacy as follows: 1. Propranolol 40mg ¼ po bid 2. Paracetamol 500mg 2 po q8h prn pain 3. B-complex 100cc IV qd x 3d (given at SHCH ED) 4. Omeprazole 20mg 1 po qd 5. MTV 1 po qd 6. Docusate gel 100mg 1 po qhs prn constipation Patient will be referred back to SHCH surgical department for elective procedure of hernia repair. Patient PT#00036, 47F, Village IIIFinal assessment: 1) Gastritis 2) GERD? This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows: 1. Cimetidine 400mg 1 tab bid x 30d 2. Metochlopramide 10mg 1 po qd x 7d If symptoms do not improve in one month, may consider using omeprazole. Patient MV#00037, 2M, Chey Udom VillageFinal assessment: 1) VSD? 2) Valvular heart dz? This patient was prescribed with medications from RPH pharmacy as follows: 1. Digoxin 60microgram po bid 2. Furosemide 8mg po bid 3. ASA 500mg 1/5 tab po qd This patient will be referred to Pediatric Heart Center in Phnom Penh near Calmette Hospital for further evaluation. Patient CS#00038, 56F, Village IIIFinal assessment: 1) PUD 2) HTN This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows: 1. Atenolol 50mg 1 tab po qd x 30d 2. Amoxicillin 500mg 2 po bid x 14d 3. Metronidazole 250mg 2 tab po bid x 14d 4. Omeprazole 20mg 1 po bid x 14d Patient TP#00039, 35F, Prao VillageFinal assessment: 1) Lung Abcess 2) Cholecystitis?? This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows: 1. Ceftriaxone 2g IV qd x 10d (available in the market) 2. Metronidazole 500mg IV tid x 10d Sputum will be collected for gram stain as advised. If positive for Klebsiella, start patient on Clindamycin 300mg po qid with water for 3-4 weeks. Patient CS#00040, 22F, Village IFinal assessment: 1) Pneumonia? 2) PTB? 3) RVH 4) Pulmonary HTN vs. MS?? Previous medications (Furosemide and Digoxin) were discontinued and this patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows: 1. Amoxicillin 500mg 1 tab po tid x 7d 2. ASA 500mg ¼ tab po qd Refer patient to Phnom Penh for 2D cardiac echo and recheck AFB sputum smears. Patient IP#00041, 58M, Village IFinal assessment: 1) PTB 2) PUD This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows: 1. TB medications according to national protocol (tx 1 week already) 2. Amoxicillin 500mg 2 po bid x 7d 3. Metronidazole 250mg 2 tab po bid x 7d 4. Omeprazole 20mg 1 po bid x 7d This patient has been treated for H. pylori eradication for 1 week already and after one more week of eradication, patient will continue with omeprazole 20mg 1 po qd for 2 more months. Repeat sputum gram stain, EKG and AFB sputum smears. Patient ST#00042, 53F, Sre Angkrung VillageFinal assessment: 1) Left Breast Cancer with possible metastasis Patient will undergo surgical procedure of modified radical mastectomy including pectoralis fascia and axillary LN clearance; if pectoralis fascia invaded, then perform total mastectomy (i.e. with removal of left pectoralis muscles).
The next Rattanakiri TM
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